=====================================================
General NPI Number Information
=====================================================
NPI Number | 1578151445
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHARLIE DELAVAN MS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2021
-----------------------------------------------------
Last Update Date | 03/19/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1818 WESTLAKE AVE N STE 312
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98109-2707
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 206-745-2764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2333 NE 128TH ST
-----------------------------------------------------
City | SEATTLE
-----------------------------------------------------
State | WA
-----------------------------------------------------
Zip | 98125-4228
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 916-704-3054
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MG60820343
-----------------------------------------------------
License Number State | WA
-----------------------------------------------------